Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.

Monday, August 20, 2007

New Rules

Interesting news:

"In one of the darker ironies in American health care, hospitals are often paid extra to treat the problems that arise when they make mistakes. Starting late next year, Medicare won’t pay for treatment for some conditions associated with screw-ups.

Under a little-noticed new rulebook that came down last week, Medicare will return the bill unpaid for care to solve these problems:

Bed-soresTwo kinds of catheter-associated infectionsAir embolism, or bubbles of air or gas entering the bloodstream during medical proceduresMediastinitis (infection of the area between the lungs) after coronary bypass surgeryGiving patients the wrong blood typeLeaving objects inside surgery patientsIn-hospital fallsThe government estimates its direct savings at about $20 million a year, and Medicare has said hospitals can’t turn around and stick patients with the tab. Other insurers are likely to follow suit, and hospitals may well do a better job for all patients, not just those on Medicare, say some advocates of the new rules.

The American Hospital Association had proposed a narrower list, saying some bedsores and hospital-acquired infections occur even with top-notch care. The trade group wanted only “never events” — such as air embolism, blood incompatibility and leaving objects inside patients — unreimbursed.

Consumers Union, which has been campaigning for better control of hospital infections, generally applauded the new rules. “We think it’s going to be a very powerful incentive for hospitals to improve care, and also a way to contain costs,” spokesman Michael McCauley told the Health Blog."

As one who's gone on record as supporting single-payer health care, this is the sort of thing that makes the position a little hard to defend. It's not that I entirely disagree with the concept. For one thing, I never (nor do most surgeons, far as I know) charged for a re-operation, even if it wasn't for an obvious error. Plus, I have advocated greater efforts to identify measures that some doctors take to get better outcomes, and to encourage them. So this sort of thing -- in theory -- is not unwarranted. The devilment is in the details. Some items on the list are inarguable; but not all. In particular, my ears up-pricked with the inclusion on the above list of mediastinitis. That happens, in this context, to be a particularly devastating infection that can occur after open heart surgery. If survived, the costs are likely to be huge. But here's the thing: there are steps we all take to prevent surgical infection; and we know that nothing is 100% effective. (The same can be said for certain kinds of air embolism.)

I can't say for sure, based on the articles I've read, but I infer these decisions will apply even if all appropriate steps were taken. Maybe there'll be fine print by which decisions can be appealed, but surely the bureaucracy will be daunting. I'm no heart surgeon; but wound infections can occur in any circumstances, despite the most scrupulous efforts to prevent them. What will be next? Orthopedic appliance infections (artificial knees, hips, etc) are awful occurances. Typical operating rooms in which they are implanted are cathedrals of carefulness: the operating teams can look like astronauts repairing the Hubble. Should a hospital that has gone to the expense of providing such a level of sterile isolation be penalized for the inevitable rare failure? Certainly, the patient will have suffered many consequences, and financial ones ought not be on the list. But hospitals have a hard enough time hanging in there financially already.

Without question, steps are needed to contain costs, and pressure to produce the highest possible levels of safety are justifiable -- more than that: they're required. It's one thing to penalize when failure to follow proper protocols occur. My concern is for events that happen when everything has been done right: there's simply no way to eliminate it completely. My prediction: once this policy is in place, we'll hear many examples of excellent care being penalized; and we'll see the list steadily expanded. It seems like the most fertile of soil in which to plant the seeds of unintended consequences. Time will tell.

[Unrelated statement: this blog seems to be experiencing an outflow problem. I'm of that age, of course; but I'm not sure the obstruction is amenable to the sorts of things a urologist might suggest. I could shove some Flomax up my nose, or into my ears, or sleep with it under my pillow. But I'm not optimistic. Just so you know.]

23 comments:

Anonymous
said...

The prototypical badly controlled type-2 diabetic, after many years of hyperglycaemia, is usually a walking textbook for internal medicine. Hospitalise him for a cardiac procedure, follow up with a pressure sore that gets infected by the MRSA that the patient was already colonised with, and watch as the toes rot off due to compromised vascularisation -- and then wait two years, with wound vacs and whatnot, until the open sores heal.

And a single-payor system has the dictatorial power to call most of that "hospital-acquired" and "preventable".

The attending's and horpital's choices are either to let the patient sufer or die from his post-op complications (hello, lawsuit); or to treat him for a few years as a freebie; or to not eve treat him in the first place.

I invite everyone to place a bet as to which of the three will happen.

Cheers,Felix.

Word verification: "brahyp" -- a particularly modern and fashionable undergarment.

I wonder how it would work over here in the NHS, and would really welcome more attention being paid to the reduction of these bad outcomes instead of always having to meet government targets and having to cope with (often inept) management.

Very well said Dr. Sid,I am worried that there will be many "unintentioned" consequences. Most of us do our best to try to prevent additional problems (not create them as implied for more payment)so the patient can recover from whatever brought them to us (heart disease, pneumonia, etc). So why not pay the hospital for the supplies they use (how are they going to seperate it all out?) in caring for the patient. That money is what is used to pay personel (nurses, cleaning staff, etc). How many hospitals will either not take the admissions (complex ones) or end up closing due to the financial burdens of those catheter infections (some can not be taken out in a week--comatose patients, etc) or postop infections (the ones that occur no matter how many precautions you take). What a mess!

The already-present MRSA infection you hypothesized brings up what other writers have already mentioned: in order to differentiate community-acquired infections from hospital-acquired ones, hospitals will have to administer a battery of admission tests they do not do so already. They have also predicted more wide-range preemptive antibiotic usage in an attempt to stave off the financial penalties. Defensive medicine at its finest.

Since I am neither a trained doctor nor a hospital financial administrator, I'll be interested to see how preemptive testing costs will weigh up against Medicare reimbursement, and whether or not hospital-acquired infection numbers will decrease (not counting the inevitable decrease once previously-acquired infections are excluded from hospital reporting).

Like so many other things about health care, I wonder if people could imagine what it would be like if their work their jobs were managed like this.It would be nice for CMS to try this out on their own workers first -- if you make a mistake, either a commission or an omission, you don't get paid for that work.About all this is going to do is increase bureaucracy on both sides, in the hospitals and in CMS, and probably erase any potential savings that could come from this.I'm always amazed at the gargantuan numbers that are alleged to be able to be saved by these measures.

Physicians are infatuated with the "specialness" of their jobs. Contrary to Sid's cathedral of cleanliness crap -- as with everything else, one makes the right incentives, behavior will change.

Undoubtedly, people will think of cleverer ways of preventing infection, preventing bed sores, etc. if they will not be reimbursed for treating them.

Will it be "unfair" sometimes in that people who did their best will be penalized? Undoubtedly. However, if aggregate numbers improve, the policy will be a success.

It goes the heart of doctor's hypocrisy--and fundamental erroneous mindset--that all regulations of them (this medicare reimbursementpolicy, malpractice) must somehow be perfect or else it is a grave injustice. Yet, when they screw up, well, sh-- happens.

Sid and your evil corrupt fellow doctors, I hope you get your single payer plan. It will be what you deserve ;-)

I will be very interested to see how long it takes before the private payors adopt the same philosophy on reimbursement for non-Medicare patients; and for either the Feds or private payors to extend this same concept to ambulatory care. Will hospitals or physicians be more reluctant to accept medically-complex patients due to a higher risk of these complications?

Some of these scenarios already happen in ambulatory care, for example, sponges or other foreign objects can be left in patients in an ambulatory surgery center.

For the person who commented on people coming up with new ways of preventing bedsores etc. Well, if that's all that would happen well I guess it wouldn't be so bad, but any intelligent person is going to know that's NOT what is going to happen. What will surely happen is those doctors and hospitals who are really doing their best will end up being punished for things beyond their control. Let's be honest, doctors are only people and as great as they may be at their profession, they still can't fix everything, some problems are inevitable. On top of that, the few doctors who maybe aren't working as hard could simply refuse to treat high risk patients.

I'm living in Canada so our issues with health care are different than those in the US but it is always scarry to think of how many people aren't getting or will not be able to get proper health care because someone is worried who is going to pay for it.

What a completly ass-backward way of addressing this. Only a beaurocrat could come up with this.

If anything's been learned from any number of systems where self-reporting occurs it's that you don't harshly penalize it or else things don't get reported. The incentives with this should be turned on their head and better care be rewarded if you really want to improve these things.

It is impossible to make serious dents in the rates of bed sores, catherter infections, and even mediastinitis in the population of patients who often develop these. There are just too many variables outside of our control for that.

Clearly the "never" events shold be tartgeted for non coverage as those are easily prevented. Everything else needs to be approached more pragmatically.

You also going to get into difficult scenarios with this as many such patients are transfered between nursing homes and different hospitals. Will accepting facilities not be compensated because a pressure sore happened at another hospital?

There are going to be as many unforseen consequences with this as there have been for EMTLA (the ER rules re. coverage and care) which has been both confusing and a disaster in many ways.

I definitely see how the details of a policy like this make the difference between good and bad outcomes. It's a risk. At the same time, I have a hard time believing that there isn't a lot of room for improvement. Didn't the anasthesia field take on an extensive study of their practices and identify a lot of ways to reduce the risks to their patients and improve outcomes? I don't get the sense that other medical fields have performed similar analyses. Certainly they would be expensive, but there is a lot of potential benefit.

I am in engineering, not medicine, and my company is currently implementing a bunch of new quality control policies to gain a certification. From now on we're going to have to follow specific procedures much more closely and document everything more thoroughly. It's a pain in the butt. On the other hand, these procedures are all things we should have been doing all along as good engineering practice, they are things we thought we were doing all along, and we're already seeing a benefit in fewer mistakes and problems as we implement the new policies. On the whole the new policies seem likely to save us time since we will have to take fewer corrective actions.

Medicine isn't engineering, of course, but I think the experience of the anasthesiologists suggests that some similar quality control thinking could do a lot of good.

This medicare policy seems like an effort to encourage this, which is not to say that it will be applied correctly.

Emily: I'd say that efforts such as those to which you refer are being made across all fields of medicine at this point. "Best practices" is the new catch-phrase, and it's being addressed very seriously. The American College Surgeons, with which I'm most familiar, is working very hard on meaningful criteria and methodology. And there's no doubt in my mind that various pressures exerted by insurers and governments (not to mention lawyers!) have had a positive effect in many ways and in many areas. This new medicare plan could, in principle, be effective. As I said, the devilment is in the details -- and in the implementation. It'll be interesting to see it play out. I'm not optimisitic that it'll end up doing more good than harm. And for now, it's hospitals that will suffer the most, I'd guess.

Medicine is not really a good analogy for engineering in that no two "widgets" are alike in terms of risk factors for some of these conditions.

Anesthesia is very a narrowly focused event in scope and time which lends itself to repetative checklist and procedures in a way that indefinite hospital care of high risk patients does not. There are clinical pathways for many of the complications listed, but for some of these there's not enough ability or manpower in the world to prevent.

2 Comments:1) Dr. Sid, YOU may never have charged for a re-operation, but the hospital definitely did, as did all the ancillary services, and, in our particular case, so did BOTH doctors.2) If medicine wishes not to be insured out of existence, it had better learn the dicipline associated with engineering quality control i.e. ISO 2001 etc. That level of anal retentiveness is the best defense to a lawsuit.

I have been on the rceiving end -- no other way to describe it -- of an ISO 9001/9002 certification process. I have also, in a different job, had a hand in shepherding a software product through a Common Criteria security evaluation.

The blithe assumption that a roomful of filing cabinets, sides bulging out, will improve anything just by its existence is fallacious. The concept may work for a "fleet in being" but not for medicine.

You are both, apparently, in engineering disciplines; you are surely familiar with the law of diminishing returns. A human life is not of infinite worth, no matter how much we would like it to be. Its worth is, to be brutal, exactly what we -- individually, via insurance, and as a society -- are willing to expend on its continued existence.

When the cost of avoiding one more post-op infection becomes so great that the whole surgical procedure turns a loss, then that procedure just will not happen.

And where Congress, that hotbed of intellectual incest and inbreeding, decides to spend other people's money (EMTALA, anyone?), the result is equally obvious:

If one desires the impossible, the most likely outcome is the worst possible. So we have inner-city hospitals shutting down, unable to bear the financial burden, and the next which two are already groaning under their current strain will now be flooded by the indigent (and, alas, junkies) who formerly frequented the first hospital's ER.

Now make that even more expensive: Not only does the hospital treat those unable (or unwilling) to pay. Not only do doctors spend their nights for free. Not only do they get sued by the people they treat. No, now the whole loss-making thing gets even more expensive!

And all that just because you, as well as those arseholes at the CMS who waste my taxes, bluntly assume that nobody in healthcare gives a hoot whether patients die like flies from infections, or whether the stink of their gangraenous rotting bedsores pervades the halls.

Ouch!Have the people writing those laws ever left their madhouse and set foot in a hospital?

Anyway, within a few years, and with a half-dozen or so more similar laws, nobody will want to become a surgeon anymore, hospitals will refuse patients, therefore nobody will risk bedsores and/or catheter associated infections, and everybody will be happy.

I'm glad to hear that a "best practices" approach is percolating its way through the various different fields of medicine. I'm sure it will have a lot of benefit for patients and doctors.

Felix, the thing I'm learning about quality control (through that same ISO certification) is that everybody thinks they're doing things the right way, covering all the details and documenting it all for future reference. We all care about doing our jobs well, we make hardware that people's lives depend upon, and we take that very seriously. At the same time, this process is showing up all the ways we routinely fail to follow those best practices. It's not about generating a room full of filing cabinets.

It's naive to think that best intentions will lead to best practices all the time.

This is true of legislation as well as medicine and engineering, unfortunately.

I too worry about the details and the consequences; it seems like all Stick and no Carrot! What we generally see at the operational end is a big spike in cumbersome paperwork and more check lists, to fill those bulging file cabinets, with a far greater documentation burden on fewer and fewer totally overstretched regular staff as dictated to by bloated top heavy Management. In numerous cases what is most urgently needed is appropriate safe levels of staffing so that we actually stand a chance of being able to implement the new standards that are handed down from above.

In my Blog I have written a lot about how the “Deliberate Negligent Understaffing” of our Medical facilities unnecessarily increases the risk of errors and infections. I have also just written a piece about insuring “Medical Risk” as apposed to the current punitive system that usually targets only Doctors or other Medical professionals, but leaves Hospitals free to perpetuate their dangerous cost cutting strategies. Just an idea, but please review this post:http://medteam.wordpress.com/insurance-covering-medical-risk/

If Medicare were to feel the need to shop around for the best facility providing treatment, based on a past track record of good outcomes and lower insurance coverage compared to similar Medical facilities, a competitive incentive would prevail. Providing a genuine incentive to make sure that your facility offers the best option with the lowest level of complications compared with other facilities does not demand the impossible by denying reimbursement for all bad outcomes. The system where we can always find someone to blame when things go wrong does not provide any incentive for patient compliance and this is also a contributing factor in bad outcomes. If insurance risk is assessed based on all of the variables then everyone is invested in working towards the best outcome; something that is sadly lacking in the current punitive system, seeking to devise even more punitive measures for the future!

t.c.: As I said, it's all about implementation. If the idea is to eliminate certain problems, whether we're talking medicine or making widgets, part of the question is whether it's more effective simply to punish the errors or also to encourage in some way the exceeding of standards. Do you only punish your kid for being bad, or do you also pat him on the head when he's good? If a doctor screws up, it's fair (depending on what exactly is the screw-up, by what definition, and assuming the conclusion is correct as opposed to a bureaucratic alogrithym that may or may not make sense) not to pay her/him. The issue, as I and several commenters raised it, is whether the new medicare list is sensible, where it will go from here, how it will be implemented and adjudicated. I have no blanket problem with the concept. Having had to try to reason with medicare and other payers over overt idiocy, I'm not sanguine about the prospects. Is all I'm saying.

I am not suggesting that there should be zero consequences for bad practice. In the piece regarding Medical Risk on my Blog site: TRANSPARENCY for EQUAL ACCOUNTABILITY in MEDICINE, I attempt to make an important distinction between “bad outcome” and “bad or negligent practice.” This is the problem with the simplistic short list of consequences that will not be covered by Medicare: the danger is that in certain cases it will fail to distinguish between the two. I have reiterated the suggestion from other sources that genuine negligence or Malpractice should be investigated by medically trained, independent Investigators and handled by a dedicated Medical Tribunal rather that the conventional Court system. Reserving punitive judgments for serious negligence cases encourages the transparency of M&Ms to identify areas of concern where improvements can be made.

Relying on the “bad Doctor” “uncaring Nurse” scapegoat, Malpractice rarely targets underlying systemic problems. Medical facilities have to assume greater responsibility for ignoring unacceptable standards of practice and the obvious risks caused by unnecessary fatigue through deliberate negligent understaffing. I insist upon using this term as it has been consciously employed to sustain the ongoing exploitation of staff, thereby deliberately endangering patient safety. The emphasis on insuring Medical risk provides benefit coverage to pay for the additional costs associated with extending Medical treatment. The price paid for human error mistakes from overworked staff, lapses in vigilance or substandard hygiene are not overlooked, far from it, they are soon reflected in higher premiums and a poor reputation for badly run institutions which forces them to change.

There are numerous variables regarding Medical outcome, but unrealistic limitations on payments within a system where all participants are not equally invested in working towards the best outcome, will not correct the problem. Any measures driven by financial consequences will stimulate protective strategies to control or eliminate risk. The question here is, will financially punitive measures requiring the impossible expectation of a zero infection rate in all cases, achieve the objective of higher standards? Probably not but, higher insurance premiums and a damaged reputation might stimulate a more proactive response. The motivation factor must always remain paramount, with efforts to eliminate infection and other risks proving a far less costly solution than simply excluding a specific cohort of patients who are currently known to be at higher risk. The Diabetic patients described above are a prime example of an area where improved standards and greater vigilance will never be enough to completely eliminate risk.

The reality is that Medical facilities will not accept financial liability for patients whose anticipated response to treatment based on reliable projections, includes a high probability of infection for which no reimbursement is possible under Medicare. Unfortunately, the industry will work extremely hard to find ways to simply exclude these patients from any access to care. We need to provide incentives that improve standards of care without relying on measures that might restrict access to care. I believe we must rethink our strategy for contending with the additional expense incurred by all types of bad Medical consequences and this might best be achieved by creating insurance to cover Medical risk and spreading the cost so that all parties are totally invested in excellent results.

About Me

I'm a mostly retired general surgeon. With my surgical blog, my intention is to inform, entertain, and possibly educate the reader about surgery, and about the life and loves of a surgeon: this one, anyway. Don't know what I'm thinking, doing a political blog, too.
In an amazing coincidence, I've also written a book, "Cutting Remarks; Insights and Recollections of a Surgeon." It's about my surgical training in San Francisco in the 1970s, aimed at the lay reader with the goal of entertaining with good stories, informing with understandable details of surgical anatomy, procedures, and diseases. Knowing you, I bet you'd enjoy it. In fact, if you like Surgeonsblog, you'll absolutely love the book!

Boring, Unoriginal, but Important Disclaimer:

What I say here is as true as I can make it, based on my experience as a surgeon. Still, in no way is it intended as specific medical advice for any condition. For that, you need to consult your own doctors, who actually know you. I hope you'll find things of interest and amusement here; maybe useful information. But please, please, PLEASE understand: this blog ought not be used in any way to provide the reader with ideas about diagnosis or treatment of any symptoms or disease. Also, as you'd expect, when I describe patients, I've changed many personal details: age, sex, occupation -- enough to make them into no one you might actually know. Thanks, and enjoy the blog.